Introduction: Physician wellness has garnered significant recent national attention within graduate medical education (GME). Unfortunately, the resources to proactively address burnout, depression, and suicide are lacking. The “Time to Talk About It: Physician Depression and Suicide” video/discussion session is specifically designed for the GME community.

Methods: The primary focus of this 60-minute video/discussion session is to promote an open dialogue among interns, residents, and fellows about depression and suicide within the profession of medicine. The centerpiece of the session is a 7-minute video featuring personal accounts from physicians at the San Antonio Uniformed Services Health Education Consortium (SAUSHEC). The materials associated with the publication include the video, a guide for facilitating group discussion following the video, a list of questions to guide small-group discussions, a session evaluation form, and examples of mental health resources for distribution at the end of the session.

Results: A field test of the video/discussion session with 22 trainees from the pediatrics residency program at SAUSHEC was very well received. Their average response to “This session was an effective first step in promoting an open dialogue among physicians about depression and suicide within the profession” was 4.5 out of 5 (i.e., Strongly Agree). One hundred percent of participants answered “Yes” to the question “Would you recommend this session to other physicians?”

Discussion: We hope that this resource will be useful to other institutions around the country as they confront physician burnout, depression, and suicide.

Educational Objectives

By the end of this session, learners will be able to:

Explain the importance of an open dialogue among physicians about depression and suicide within the profession.

Describe the stigma surrounding depression and help-seeking behaviors among physicians.

Discuss the benefits of an environment that encourages caring vigilance among colleagues and appropriate help-seeking behaviors for depression and suicidal ideation.

Introduction

The culture of medicine may be at an inflection point when it comes to behavioral health issues among physicians. The traditional stigmatization, lack of confidentiality, and fear of professional repercussions are gradually being replaced by transparency and encouragement for appropriate help-seeking behaviors. Literature on physician wellness, resiliency, burnout, depression, and suicide is ever increasing and gaining significant attention in news and social media outlets. 1-3 These issues have also gained the full attention of the Accreditation Council for Graduate Medical Education (ACGME), which now requires training programs to ensure they are “promoting . . . resident well-being in a supportive educational environment.”

Unfortunately, the resources for proactively addressing burnout, depression, and suicide among GME physicians are lacking.

The genesis of the “Time to Talk About It: Physician Depression and Suicide” video/discussion session was the tragic loss of a San Antonio Uniformed Service Health Education Consortium (SAUSHEC) intern in August 2014. During intern orientation the following summer, a small group of SAUSHEC physicians came together on stage to share personal accounts of colleagues and family members who had committed suicide, as well as individual struggles with burnout, depression, and suicidal ideation. The video recording of their presentation was shared with a small number of other institutions that had become aware of it by word of mouth, and before long, additional institutions were requesting copies of the video as well. What had started as a simple presentation at our local intern orientation had become something much more significant—an instrument to satisfy a genuine need in the GME community. With this in mind, we made the decision to convert the rough-cut video into a professional production to be shared with institutions around the country.

The session consists of a powerful 7-minute video, followed by a 30- to 45-minute small-group discussion session. The video features the following personal narratives by physicians (not actors):

A resident’s reaction to her (then) intern colleague’s suicide.

A fellow’s personal struggle with depression and suicidal ideation.

A faculty physician’s reflection on the loss of his younger brother (a resident at the time) to suicide.

The goals for the session were both to promote open dialogue among physicians about depression and suicide within the profession and to confront the stigma surrounding depression and suicide within the profession. A third goal was to foster an environment that encourages careful vigilance among colleagues and appropriate help-seeking for depression and suicidal ideation.

Methods

Target AudienceWe recommend conducting sessions with interns/residents or fellows from individual GME programs, given their baseline familiarity with one another. We postulate this will expedite the goals of changing the culture and encouraging trainees to intervene for one another. However, this is not intended to prohibit sessions with trainees from multiple programs (if necessary), provided that effective facilitator support can be arranged.

Logistics and Facilitation SchemaThe session requires an uninterrupted minimum of approximately 60 minutes, but there may be certain programs that require more time to allow for complete discussion. The Facilitator Guide (Appendix B) is used to help instructors navigate the session. This guide outlines the session objectives, offers recommendations for different portions of the exercise, provides suggestions for improving success, and provides common themes/feedback from our small-group sessions. The facilitation schema is as follows:

One to two group facilitators who are not (ideally) from the same GME program as the participants. This is intended to encourage maximum participation from trainees who might not be comfortable sharing sensitive information with members of their program faculty present.

Conference room large enough for an individual GME program’s trainees.

Computer (for accessing video file) and television/projection screen.

Resource folders for distribution after the session evaluation (see Appendices D-G for examples). Ideally, these folders should contain specific contacts/resources in the immediate area. If these are not available at the local institution, more generalized resources can be substituted.

Given that the video has the potential to evoke strong emotions—especially for trainees experiencing depression/suicidality or with pertinent past experiences—someone with group therapy training and/or a mental health background should be present or available.

PreparationFacilitators should be familiar with the Facilitator Guide (Appendix B) prior to the video/discussion session. In an effort to encourage maximum participation, they should carefully consider how they plan to establish group trust and assure participants of privacy and confidentiality.

Deployment and Lessons LearnedIn November 2015, we shared an initial draft of the video with leaders and participants at the first ACGME Physician Well-Being Symposium. In March 2016, we completed a field test with 22 interns and residents from our pediatrics program. From this experience, we found that facilitators need to be mentally prepared for a wide range of responses from the group—anything from awkward silences (especially at the beginning of the discussion) to personal anecdotes and emotive responses of all varieties. We also found that the guided questions included in Appendices B and C work best as a means to prompt open-ended conversation and should not be treated as ends in and of themselves. In other words, it is not mandatory to get to each of the guided questions. Finally, we determined that the session is most successful if participants interact with each other, with as little involvement from the facilitators as possible. The session is not designed to be a Q&A session but rather an opportunity for trainees to talk to one another.

Results

In March 2016, we performed a field test of our video/discussion session with 22 trainees from our pediatrics residency program. All 22 completed an evaluation at the end of the session.

Most residents strongly agreed (4.5 out of 5) with the statement “This session was an effective first step in promoting an open dialogue among physicians about depression and suicide within the profession.” They also strongly agreed with the statements “This session was an effective first step in confronting the stigma surrounding depression and help-seeking among physicians” (4.4 out of 5) and “This session was an effective first step in fostering an environment that encourages appropriate help-seeking for depression and suicidal ideation among physicians” (4.4 out of 5). One hundred percent of the participants indicated that they would recommend this session to other physicians.

Discussion

To the best of our knowledge, this video/discussion session is the first of its kind in the GME community. We hope that it will serve as a valuable resource to institutions around the country as they confront these difficult issues.

Here at SAUSHEC, our intent is to conduct this session with each of our 35 GME programs over the course of 6 to 9 months in the new academic year. For the first year of implementation, we plan to utilize the same two facilitators who administered the March 2016 field test. We hope that this consistent approach will provide us with additional feedback and enable us to successfully train/prepare multiple facilitators for the future.

Using the existing video and making adjustments and customizations to the Facilitator Guide, there are several additional opportunities that we plan to pursue in the coming months. One opportunity involves creating a session for faculty physicians. Just as trainees may be uncomfortable discussing these issues with faculty members present, there may also be staff physicians who are uncomfortable discussing sensitive topics with their trainees in the audience. A second opportunity involves creating a session for a combined group of faculty physicians and trainees once the culture of physician wellness has been firmly established. These sessions may eventually be expanded to include faculty interns, residents, and fellows. Finally, we see extending this video/discussion session to medical students as a third opportunity for expansion.